So instead I'll be spending the morning watching how my iPad is going to make my life awesome. Oh, when will iPadmas finally get here? I ordered mine (of course I ordered one) on the first day preorders were available, but since I opted for the 3G model it doesn't ship until "late April."

26 March 2010

Amazing. I've used photoshop for years, and I've always been painfully aware that my photoshop skills are completely lame; I use about 10% of what that programs can do. But this, this is an incredibly cool and powerful tool. Worth the (substantial) upgrade cost.

The tech, as per protocol, dropped the ECG on my desk within three minutes of its being completed, along with the chart. He was visibly excited. I glanced at the ECG and the triage note. In the standard terse nursing verbiage, it read "CC: Ground Level Fall. Too weak to get out of bed. No injury reported. No other complaints." There was an included prior ECG, which was normal. Today's looked like this:"Should I call the cath lab?" the tech asked. We pride ourselves in having the best door-to-dilation time in the region, and it's a key focus of our department protocols that patients with an "Acute MI" or heart attack need to be expedited to the cath lab. The tech had seen the computer interpretation of "ACUTE MI" and was rarin' to go.

I have learned not to trust the computer. The only thing it can reliably interpret is "Normal" and even then it is sometimes wrong.

So, as several of the commenters correctly guessed, I ordered a stat chemistry panel, and the serum potassium was resulted at 8.5 (normal = 3.5-4.5), which should not be surprising because, once I took the drastic step of meeting and interviewing the patient, he has kidney failure and is dialysis dependent. He was too weak to get out of bed for dialysis and so had missed his appointment, which was part of the reason his potassium was elevated. The other part? I'll get to that.

So,hyperkalemia(medicalese for "high potassium") is one of those things that is a true emergency, that can be immediately lethal if not treated, and one of the few things that really gets an ER doctor moving. Potassium is involved in maintaining the electrical gradient which allows muscle and nerve cells to function -- excessive potassium in the bloodstream poisons the ability of these cells to operate normally. This accounts for the patient's generalized weakness. The Bad Thing that can happen is that the heart muscle can be affected -- in this case, the heart muscle was no longer contracting briskly in unison over the usual 100 milliseconds or so, but rather contracting sluggishly over a period of 200 msec; you can see how wide and ugly the spikes (QRS complex) are on the above ECG. It was still pumping OK, but the risk is that this makes the heart very vulnerable to arrhythmia, that any minor disruption, like a premature beat, could induce irrecoverableventricular fibrillation.

Fortunately for adrenaline junkies like me, there is an antidote: a cocktail of Calcium, Sodium Bicarbonate, and insulin, which can very quickly mitigate the effects of hyperkalemia. the bicarb and insulin activate ion pumps which move the potassium inside of cells, which temporarily "hides" the excess potassium from the heart. Calcium buffers the heart cell membranes and stabilizes them from the ill effects of the potassium. It's extremely gratifying. It doesn't fix the problem, but generally buys you enough time to get the patient to dialysis, which will remove the potassium from the bloodstream. Calcium works fastest and should always be given first in these situations. Here's how it worked for us:And the after-treatment ECG:Notice the nice narrow QRS complexes. Much better looking. And off he went for emergency dialysis.

And as for the "why" -- well, he had a dedicated and caring wife. She was very concerned about the general decline in his health since he had been on dialysis, and that in particular he was losing weight and malnourished because he no longer had the appetite he once did. So over the weekend, she went and got him some really nutritious vegetable juice -- V8.Chock full o' potassium. 470 mg per serving. Sheesh.

25 March 2010

On another note, it's interesting to see that as the furor dies down, people's heads are cooling off and some semblance of sanity is returning. A lot of people commented on an ugly, ugly video of Teabaggers viciously berating a man with Parkinson's. It could serve as a symbol of all that has gone wrong with our political discourse over the last year. There is some follow-up, though, and it's somehow affirming:

The man who berated and tossed dollar bills at a man with Parkinson's disease during a health care protest last week says he is remorseful and scared."I snapped. I absolutely snapped and I can't explain it any other way," said Chris Reichert of Victorian Village, in a Dispatch interview.

In his first comments on an incident that went viral across the Internet and was repeatedly played on cable television news shows, Reichert said he is sorry about his confrontation with Robert A. Letcher, 60, of the North Side. Letcher, a former nuclear engineer who suffers from Parkinson's, was verbally attacked as he sat before anti-health care demonstrators in front of Rep. Mary Jo Kilroy's district office last week.

"He's got every right to do what he did and some may say I did too, but what I did was shameful," Reichert said. "I haven't slept since that day."

"I made a donation (to a local Parkinson's disease group) and that starts the healing process."

I'm glad to see that, for all involved. I hope that the anger and the hysteria and the subtle or not so subtle threats of violence will be allowed to fade away now that the deal is done.

Of course with the Becks and the Limbaughs and the Palins out there still fanning the flames of rage, that may not be likely. But I hope that people turn them off and take a deep breath and relax.

There was a little buzz on Twitter last night that the Democrats in the Senate had killed an amendment which would have prohibited federal funding for Erectile Dysfunction medications for sex offenders, which means in the upside-down logic of Washington DC that the Democrats favor giving Viagra to pedophiles. Right?

Well, not exactly.

First, just a point of procedure: Remember, the Health Care Reform Law is now law, on the books, signed by the President. But there was this reconciliation side-car bill which was meant to fix the HCR Law as originally passed; it was passed in the House pretty much as soon as the Senate bill was passed. But it had to pass the Senate in the identical form, word for word, in order to go directly to Obama's desk for signing. If the Senate mucked things up by tacking on amendments, it would have to go back to the House for approval -- and given the razor-thin margin in the House, Democrats very much wanted to avoid that. So, in a rare display of caucus discipline, the Senate Dems decided not to offer or approve any amendments at all.

It's worth noting that progressives in particular passed on a real opportunity here. They could have tacked on a public option or medicare buy-in fairly easily, since the Nelson-Lincoln-Lieberman veto would have been irrelevant. They decided not to, in part because they didn't want to screw up the deal that had been struck, and in part out of sheer exhaustion.

The Senate GOP, however, saw this as a great opportunity to have a little political fun. If they could attach a poison-pill amendment, it could kill the reconciliation bill outright. (Of course, we'd still have HCR passed, but a smaller and more flawed version.) Better yet, they could make the Democrats take a series of embarrassing votes that could be used as campaign attack ads come November.

Hence, the "No viagra for sex offenders" amendment was born. Along with 28 other frivolous amendments, including a couple which would have repealed HCR entirely, they were offered and defeated last night.

Bear in mind that there isn't currently a "sex offenders get free viagra" clause in the HCR bill that needed removing. Sure it's possible that a sex offender could buy a subsidized health insurance policy that covered erectile dysfunction, but then a lot of things are possible under HCR -- maybe panty-sniffing fetishists will want sex changes. Whatever. This amendment wasn't about a good faith effort to address the issue; it was an effort to embarrass Democrats. And just in case there was any possibility that the Dems might have approved the amendment, he tacked on one other line: "prohibits coverage of abortion drugs." Which of course would have blown up the whole thing if it did pass, making it even more of a must-defeat amendment. Funny how the "Viagra" element got all the press and the abortion rider was never mentioned, eh?

I don't disapprove of this sort of tactic, other than as a mild waste of time in an institution that wastes a lot of time on stunts and grandstanding. And you have to give credit to professional jackass Senator Coburn -- this amendment is a work of art, in its way. Nothing wrong with it, and the Democrats would be well advised to make the Republicans take some hard votes in the same manner.

But understand it for what it is: theater and attack-ad fodder, not a serious effort at governing.

24 March 2010

Got a tour of our new hospital yesterday. Remembered my camera this time, but unfortunately they hustled us through the ED pretty quickly, so I only got a couple of shots (and I forgot my wide-angle lens, too, which is worse if you're trying to take architecture pictures). But it was cool, especially going up on the roof to see the new helipad, the ICU in its very rough stages, and the simply awe-inspiring wide-open elevator shafts. This building is made solid -- amazingly so -- cross-bracing engineered to withstand an 8.8-magnitude earthquake and glass paneling which can flex 2.5 inches to withstand sustained 70-knot winds (or more). And did I mention the ER is going to be 80 beds?

If you want to see what a new 350-bed hospital looks like in the final stages of rough construction looks like, feast your eyes on these pictures. Envy me. But, like Christmas, the waiting is the hardest part. We are three months ahead of schedule and under budget, but we still don't open until June 2011. (sigh)

23 March 2010

Let it be noted: I have never claimed that the HCR bill is perfect. Far from it. However, despite its many flaws it provides a framework for the future health care financing system, and now that it is law it is time to begin work on fleshing out the details, filling the gaps, and fixing the bad bits of the bill.

[HCR] basically ensures that adverse selection will happen on a massive scale. If everyone can buy the same level of insurance, regardless of their health condition, the people who are most likely to buy it are those with preexisting conditions who expect to undergo expensive procedures. As high-cost patients sign on, the insurer must cover these costs by increasing its rates, thus making health insurance a worse and worse deal for relatively low-cost healthy people. As healthy people drop out, premiums must rise further. After several iterations of this, the equilibrium is a series of very expensive insurance pools covering the sickest and most costly-to-treat patients, with everyone else priced out of the market. What this really means is that the winning strategy is not having health insurance while you’re healthy, and then signing up for it when you come down with an expensive ailment – there’s no way the insurance company can turn you down, and they have to foot the bill.

A very legitimate concern. The penalties for not purchasing insurance are not strong enough. (I should point out that the more liberal House bill had stronger penalties, but water under the bridge...) There is a risk that people will game the system like this, and based on the current numbers they will win:

An individual who is not eligible for the subsidized exchange plans would be making 400% of the federal poverty level -- or around $44,000 in today's dollars. The 2016 penalty for an individual who is unsubsizided is $695 or 2.5% of income, which for this person would be $1100. The bronze level annual premium is estimated to be $5800 in 2016. While most people will prefer to get something (insurance!) for their money, a certain number of (healthy) people will choose instead to pay $1100 for nothing and bank the difference.

The CBO did take this into account, and their estimate (PDF, page 19) of the number of people who will do this is low, based on the fact that for most people the cost of insurance will be subsidized. I found it difficult to quantify, but the CBO also estimates (PDF, page 8) that 95% of the adult, non-elderly, legal population will be enrolled in some health care coverage when the plan is fully implemented. About 20 million will remain uninsured. Of those some will be medicaid-eligibles who for whatever reason do not manage to sign up, but about 4-5 million will be people who would be in the non-group market, in the exchanges, who would not have received subsidies, and chose not to sign up (if I am reading the chart right). The CBO estimates that there will be some 30 million people covered in the exchanges. If there are 5 million people who are truly part of the risk pool for then exchanges but are not contributing to the premium pool (understanding that they are able to opt in when they need it), is that enough to induce an adverse selection death spiral? I dunno -- I an not an actuary. But it's concerning that a sixth of the risk pool can choose not to sign up.

My take: now that we've gotten over the idea that the individual mandate and universal coverage is part of American law, the mandate should be strengthened to the point that it is effective. Ideally, the penalities for not signing up should be more or less equivalent to the premiums that person would have paid under the bronze-level plan in the exchange, taking subsidies and what-not into account.

Fortunately, we have a few years. As the partisan rancor dies down and Congress moves on to less ideological, technical legislation over the subsequent years, perhaps this item can be addressed in a bipartisan manner to ensure that the system actually works.

Obama ran as the candidate who could be post-partisan; he ran on the idea of being a mediator, someone who could bring all sides of the table and forge reasonable consensus. That hasn't really worked out, has, it, and now in the wake of the passage of the party-line healthcare reform bill, I fully anticipate more "tsk, tsk, Obama has failed to be a uniter like he promised" articles to be published by Very Thoughtful People.

Never in modern memory has a major piece of legislation passed without a single Republican vote. Even President Lyndon B. Johnson got just shy of half of Republicans in the House to vote for Medicare in 1965, a piece of legislation that was denounced with many of the same words used to oppose this one. That may be the true measure of how much has changed in Washington in the ensuing 45 years, and how Mr. Obama’s own strategy is changing with the discovery that the approach to governing he had in mind simply will not work.

“Let’s face it, he’s failed in the effort to be the nonpolarizing president, the one who can use rationality and calm debate to bridge our traditional divides,” said Peter Beinart, a liberal essayist who is publishing a history of hubris in politics. “It turns out he’s our third highly polarizing president in a row."

Oh my. Seriously, this makes me want to scream. It's like the Very Serious Pundits think that one side of a two-sided system can bring everything together. That if only Obama were just a little more thoughtful, if he compromised a little bit more, if he were just more of a uniter, the raging lunatics on the right would have come over and realized that they should compromise after all! Clearly the radicalization and intransigence of the Republican party is Obama's fault.

In fact, the use of the term "polarizing" itself is a dead giveaway of the preconceived narrative the author is trying to promote. Obama is polarizing? No -- the country itself is polarized. (Or as Digby put it, the Republican party has gone batshit insane and the country is polarized between their freakshow and normal people.)

Consider this possibility: Hillary Clinton had won the nomination and was now the president. Do you think that the right wing would be less or more apoplectic at the arrogance of the Democrats in trying to impose tyranny enact their campaign promises? Suppose John Edwards were the president (for the purpose of this hypothetical leaving aside his peccadilloes) working to address the inequalities he addressed in his "Two Americas." Would the shrieks of socialism and class warfare be louder or quieter?

Or imagine this: had the congressional Democrats pursued a truly liberal health care bill, instead of the moderate, centrist bill they did enact, say they pushed forward and somehow got something truly universal or even radical enacted. Whether it was Wyden-Bennett or single-payer or some other innovative idea., would the right-wing freakout have been less intense or more? I think you know the answer to these questions.

The situation was the same under Bill Clinton: the right wing systematically refused to accept Clinton as legitimate regardless of how conservative he tried to be. He governed as a centrist yet was met with the most hysterical opposition we had ever seen -- until now.

And it is, I might add, very much a one-way street. Obama was elected with something of a mandate: a solid electoral win with huge governing majorities. He has pursued moderate policies. Yet he is attacked as socialist. Bush lost the first election and had parity in Congress, yet came in and imposed the most hard-right policies imaginable. Obama listened to Republicans and included $300 billion of tax relief in the $700 billion stimlulus -- I cannot think of a similar case of Bush including Democratic budget priorities in a major legislative vehicle. (Though I do remember a classic bait and switch he pulled with NCLB.) And yet, democrats, at least some of them, often signed onto Bush initiatives. Yet Obama has yet to receive a single republican vote for even one of his major policies, even from GOP moderates, the few of them that still exist. And for his efforts, Obama is decried as the gravest threat to our Constitution since ... Hitler?

I'm so old when I remember when it was unpatriotic to criticize the President in a time of war.

The pattern seems to me to be this: conservatives simply cannot accept that liberals have any legitimate claim to power in this country, be it the Presidency or major legislative initiatives.

As you may know, yesterday, the U.S. House of Representatives passed a bill that restructures the nation’s healthcare system. All in all, do you think it is a good thing or a bad thing that Congress passed this bill?

Good thing 49%Bad thing 40%

America loves a winner. And the goodies haven't even started to flow yet...

The lack of Republican support for HCR is by many taken as proof that ObamaCare is somehow radical and partisan. While the vote was partisan, this has more to do with the political calculations of the congressional GOP than about the actual bill.

Key graf:

Obama's plan closely mirrors three proposals that have attracted the support of Republicans who reside within their party's mainstream: The first is the 1993 Senate Republican health plan, which is compared with Obama's planhere, with the similarity endorsed by former Republican Senator Dave Durenbergerhere. The second is the Bipartisan Policy Center plan, endorsed by Bob Dole, Howard baker, George Mitchell and Tom Daschle, which is compared to Obama's planhere. And the third, of course, is Mitt Romney's Massachusetts plan, which was crafted by the same economist who helped create Obama's plan, and which isrhetorically indistinguishablefrom Obama's.

Interesting nugget -- according to Hugh Hewitt's book praising RomneyCare, the idea of the individual mandate was first devised by .... the conservative Heritage Foundation! I don't endorse this as true, since I don't know, but it's interesting to see the right oppose policies they endorsed when they were not proposed by Democrats. (The conservatives now claim that the individual mandate is unconstitutional.)

It's also interesting to see criticism of the excise tax on high-cost employer-sponsored insurance plans, when John McCain ran for president on a pledge to tax all insurance plans. From a policy perspective, though McCain's plan was more sweeping, both have the same effect of creating consumer incentive to reduce the growth in healthcare insurance costs. Which is a conservative policy concept.

Again, I hate to sound like a broken record, but this bill, while a political victory and a step forward for America, is very much a policy victory for the conservative movement. There is no public option. There are no paths to single payer here. It's not truly universal. The employer-based healthcare financing and the privately delivered healthcare system are left intact. Whether this reflects the shitty tactical positioning of progressives, the heterogenity of the democratic party, or the degree to which fanatic republicans have shifted the frame to the right remains for philosophers to debate.

22 March 2010

For all the histrionics about the "unpopular" health care bill being "rammed" down our collective throats, it's worth noting that, even in the general state of being not too terribly well informed about the bill, the public is not all *that* opposed.

For example, consider CNN's recent poll. The topline numbers don't look too great: 59% oppose, 39% support. (BTW it's astonishing that only 2% had no opinion given how few people actually know what is in the final package.) But when you drill down a little bit, you find something interesting:

43% oppose it on the grounds that it is too liberal, while 13% oppose it on the grounds that it is not liberal enough. So another way of looking at the data is that 43% oppose it for being too liberal, 39% favor it, and 13% oppose it for not being liberal enough, with another 3% who oppose it for some indeterminate reasons.

So a not-unreasonable interpretation of this poll is that 52% are in favor of reforms in general, with about a quarter of those folks being angry & disappointed that this bill doesn't go far enough, while about 46% oppose it outright.

The overall trend still is about 50-40 opposed in national data, and if you assume even 5% of general opposition form the left, these are not numbers which portend a vitriolic backlash at the polls, especially if, as some suggest, the reforms become more popular once they are passed, once the narrative moves away from the process, once the public becomes better informed about the bill's actual content, and once the reforms start to take effect. The intensity of support/opposition should remain a concern for democrats, but I suspect that as this fight passes into the past, the enthusiasm gap (now strongly favoring the GOP) will also begin to come back closer to parity.

I'm concerned about November, but I am much more concerned about November due to the overall economy, not due to health care.

For the last year, health card reform in the media has consisted almost exclusively of process related stories: the filibuster, the gang of six, reconciliation, deem-n-pass, etc. It's all been about "who's up, who's down," who's winning, who's losing. A lot if heat and very little light.

The radio & news shows today are all about the policy implications of the bill, now that it is passed. Explaining to people what it is, what it will do, what it won't do, covering the actual details of the reforms and the effect it will have on the lives of working Americans.

Sigh. It would have been nice if the media had covered that before the bill became law. It might have resulted in a better bill, or at least easier passage of the decent bill we got.

One of the political liabilities of the HCR bill is that the most important elements -- the insurance exchanges, subsidized plans, and the expansion of Medicaid -- do not go into effect for several years, indeed until after the next presidential election. This was, lamentably, a gimmick Congress used to stay beneath an arbitrary cost ceiling imposed by President Obama. But it is what it is. So what is in the short-term horizon for health care? What effects will be seen immediately?

Shamelessly borrowing from a note that Speaker Pelosi (a close personal friend) sent me last night, here are some of the key provisions that go into effect within the next 90 days, 6 months, or year:

SMALL BUSINESS TAX CREDITS— Tax credits of up to 35 percent of premiums will be immediately available to firms that choose to offer coverage. (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)

BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Completely closes the donut hole by 2020.

Some much needed investments in Primary Care:

COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2010.

INCREASING NUMBER OF PRIMARY CARE DOCTORS—Provides new investment in training programs to increase the number of primary care doctors, nurses, and public health professionals. Effective beginning in fiscal year 2010.

ENDS RESCISSIONS—Bans health plans from dropping people from coverage when they get sick.

NO DISCRIMINATON AGAINST CHILDREN WITH PRE‐EXISTING CONDITIONS—Prohibits health plans from denying coverage to children with pre‐existing conditions. Beginning in 2014, this prohibition would apply to all persons.

BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts new plans’ use of annual limits to ensure access to needed care.

FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles.

NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan.

ENSURING VALUE FOR PREMIUM PAYMENTS—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders.

IMMEDIATE HELP FOR THE UNINSURED UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH‐RISK POOL)— Provides immediate access to insurance for Americans who are uninsured because of a pre‐existing condition ‐ through a temporary high‐risk pool.

EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE – Requires health plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice.

PROHIBITING DISCRIMINATION BASED ON SALARY—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees.

Further, despite the disingenuous rhetoric of Rep Paul Ryan, this bill does not in fact cook the books. The funding is over ten years but the benefits are over six -- that sounds damning, but this graph shows that in fact the revenue collections and offsets rise very much in lockstep with the new expenditures over the next decade:

There's a little pre-paying of spending there, but it's small, and frankly it makes sense to book the revenues before you pay out the benefits, at least to some degree. Remember, as well, that the deficit savings are projected to increase in the subsequent years, too.

Overall, this is pretty good bang for the buck in the initial years. I'd still like to see the exchanges start up immediately, but the interim high-risk pools are a nice start (are they subsidized? I'm not sure). It will definitely give the Dems some good talking points leading up to November, and hopefully will start giving consumers some needed relief.

So, at this point, it's over, except for a few housekeeping items. Last night the House passed the Senate healthcare reform bill and the reconciliation sidecar, and this essentially ended the legislative fight over reform for this Congress. Yes, technically, the Senate GOP could try to block the reconciliation bill in the Senate, but they are unlikely to be successful and even if they did the Senate bill itself will still be the law of the land. So their only motivation is to try to make a little political hay.

So what is this bill? Is it going to transform all health care instantly? Do I need to report to the death panels this week or next?

Not so much. It turns out that despite all the hullabaloo, despite the insane level of rhetoric about the death of freedom and the destruction of the Constitution, this is a fairly limited and moderate reform bill. It's funny -- as has been noticed elsewhere -- if, 14 months ago, you posited that the HCR bill would have been endorsed by the AMA, the AARP, the unions and the small business organization, and tacitly accepted by the insurers, you would have concluded that it must have been a pretty reasonable bit of legislation. And it is. It continually amazes me the frenzy which the opposition has been able to whip themselves into.

But was this a clean win for Obama and the Democrats?

David Frum, from the Bush administration, tweeted "if HCR prevails, Republicans need an accountability moment. Jim DeMint/ Rush / Beck etc. ed us to Waterloo all right . Ours." And from a pure political perspective he may be right. This is a huge defeat for Congressional Republicans, and we will now see the Democrats taking a victory lap and running on the bill, which will become progressively more popular now that the ugly process articles will fade away and the benefits start to come into effect. It's a given that the Dems will lose seats in November, but with this win under their belts it's likely that they will lose fewer than they would have otherwise. But is it, as Drum said on MSNBC, also a policy defeat for conservatives? I'm not so sure, and in fact I think that it's a bigger defeat for progressives, driven in part by the relentless opposition of the conservatives and the frustrating tendency of democrats to preemptively-compromise their positions.

Consider the two key policy priorities that liberals brought to the table:Public Option (which was for many a pre-compromise down from Single Payer)Universal Coverage

We got neither of these. There's no publicly run insurance program at all, and the expansion of insurance coverage is incomplete at best, with a weak individual mandate and a weak employer mandate. The insurance exchanges are state-run, not federal, and, worst of all, the implementation for most of these reforms is several years off.

Is it still a good bill? Yes. Is is still worth having, an improvement on the status quo? Yes. Is this a policy victory for progressives? Yes, but a decidedly mixed one. The subsidies for middle-income consumers are probably the biggest "win" for progressives, and the insurance regulations are also pretty great, though I view those as pretty consensus reforms, not progressive goals.

20 March 2010

I was disappointed when I interviewed then-ACEP President Nick Jouriles last year that ACEP had not staked out a clear position on health care reform. However, it was not terrible that they did not have a position at that time, because the House bill was still being finished up and the Senate was still mired deeply in the fruitless "Gang of six" negotiations. If ACEP was not going to endorse reforms sight unseen, that was pretty reasonable, I thought. President Jouriles suggested that, in time, ACEP would weigh in with a position, one way or the other. But we never heard ACEP take a position in the intervening months.

It's pathetic, and brings into question whether ACEP can fulfill one of its most crucial functions: advocating for Emergency Department patients, and advocating for Emergency Physicians.

The excuses offered by Dr Gardner for ACEP's reticence to take a stand are fairly lame. Specifically, she writes that this has been a continually shifting landscape for the last years, which is true enough, and she cites the "deep divisions" in opinion regarding the reforms, and instead offers up a vague set of principles which ACEP had previously laid out as its priorities in any reform bill.

Which would be fine if the House was set to vote tomorrow on a vague set of principles. We'd be all over that! But for the actual reforms, sorry, ACEP couldn't figure out, as an organization, whether it should support or oppose it. This is despite the fact that the broad outlines of reform have been perfectly visible for ages.

I remember that in Dante's Inferno -- greatest piece of 14th-century Italian poetry I ever read -- there was a special place in Hell for the Uncommitted, for those souls who, in life, couldn't decide whether they supported good or evil. (Technically, they are outside the gates of Hell. Their punishment is to eternally pursue a banner while pursued by wasps and hornets that continually sting them while maggots and other such insects drink their blood and tears. Nice!) It's sad to see an important organization like ACEP fall into this category of the pusillanimous and the timid when faced with the most important piece of health care legislation in our professional lifetimes.

And remember, ACEP does not pretend that it has no role in politics. They aggressively market their political action committee, NEMPAC, with the goal of being the most influential specialty medical society. But when they come to me and ask for money, I will ask them, "where were you when health care reform was on the table? Why should I contribute my hard-earned dollars to an organization so feckless that it couldn't even figure out its position on the bill that will impact our specialty more than any other law in three decades?" An advocacy organization that can't figure out what to advocate for (or against) is pretty useless.

And make no mistake, this bill has huge implications for Emergency Medicine. ER docs provide care for 20 million patients annually who have no insurance; the cost of providing care to the uninsured for EACH ER DOC is $125,000 per year in unreimbursed care. This bill promises to expand insurance to 31 million Americans -- their care in the ER will now be funded. This will reduce our need to cost shift to private insurers, this will provide much-needed capital to expand overburdened ERs, and this will support recruitment and retention of skilled ER docs in underserved areas. Moreover, this reform will invest in community health centers and reimbursement for primary care, to give patients options to receive non-urgent care and follow-up care in settings more appropriate than the ER.

Yet ACEP, historically dedicated to the parochial interests of EM, can't decide whether this legislation is good for Emergency Department patients and physicians.

It's true that this has been a divisive debate, and there are many of us with strong opinions. However, my experience is that most ER docs that I personally know do have a great degree of confusion about the reforms proposed. Most ER docs (shockingly) don't take time on their day off to read the CBO scores and delve into the policy details. This is why we have a professional society -- this is why we have leaders. We rely on their expertise, we rely on their efforts to prise apart the statutes and the funding and come to a conclusion and lead the organization in a chosen direction. I don't expect unanimity, and in fact for this issue I would expect a lively debate within the ACEP Council before a decision was reached -- and consensus may indeed have been elusive. But this is why we have elections and why there are processes for reaching positions, and had Dr Gardner the courage to follow these processes to a resolution, ACEP would have been in a position to influence the national debate that it now reaching its conclusion.

Dr Angela Gardner and the other leaders of ACEP have failed in this obligation to their constituents.

Effective April 16, Walgreens drugstores across the state won't take any new Medicaid patients, saying that filling their prescriptions is a money-losing proposition — the latest development in an ongoing dispute over Medicaid reimbursement.

It turns out that I don't have a lot to offer beyond the irascible Texan's observation:

Medicaid should be funded (or abolished); the current system isn’t actually fair to anyone.

Exactly my point from yesterday. It's more generally also an indictment of the structure of Medicaid -- programs for the poor are poor programs. If Medicaid beneficiaries could participate in the Medicare Part D drug benefits (presumably subsidized based on income) that would be a more sensible way to provide pharmacy benefits to the indigent.

Another annoying feature of Medicaid pharmacy benefits: that OTC meds are covered. It drives me nuts when I get a request for a prescription for ibuprofen or tylenol. I get the concept, but it doesn't seem to make sense in practice.

We use a little company called Assurant to administer the employee health insurance plan for our business. We have about 50 employees, not all of whom are on our insurance (some get theirs through a spouse), so we are in a particularly undesirable segment of the small-business market. Ironically, we have had a fair amount of difficulty in getting coverage which was affordable and sustainable. A lot of insurers wouldn't even bid on us.

So we wound up with an unusual sort of self-funded plan administered by Assurant, which was working OK. Recently, however, a couple of our doctors wound up taking family members to the ER for various reasons -- nothing serious, but common and reasonable presentations for an ER. And Assurant denied payment for the claims. They didn't deny it outright, actually, just imposed a $500 "penalty for non-emergent use of the Emergency Room" on top of the usual co-pays and deductibles.

I was appalled at what I thought was a blatant violation of our state's "prudent layperson" statute -- that any prudent layperson who thinks that they have a medical emergency and must have their ER visit covered by their insurance. There's legislation to that effect in all 50 states, I believe, and it was due to notorious bad behavior by insurers in the '90s, when they tried to control costs by routinely rejecting ER claims retrospectively, claiming they were not truly emergent. This was a political fight that ER docs had won and since then have paid very little attention to.

Turns out there's a huge loophole.

Our insurance plan -- like 60% of the private insurance market -- is organized under the federal ERISA statute. ERISA is horrifically complicated, but the upshot is that there is no prudent layperson clause in it, and the federal statute pre-empts state laws in these respects. So they can legally deny payment for ER claims, so long as the contract with the employer allows it. I happened to chat with our state's Insurance Commissioner on another topic, and they said that they did not see many complaints on this matter, since most insurance plans gave up on this tactic due to the inevitable bad PR and small cost savings from these tactics.

I followed up with Assurant -- they pointed out that this sort of review was clearly allowed in the contract we signed with them to provide coverage for our employees, and they were right. It's a big, complex agreement, and that clause had slipped by us. The reps explained (to excuse themselves) that it was a computer thing, and that something about the coding had triggered the rejections. They went on with a line of BS, though, trying to claim that they were just trying to steer consumers away from the ER and towards more appropriate avenues of care. I was pretty pissed, though, since the way they were implementing this clause was obviously beyond the pale of what was acceptable. Our employees -- Board-certified ER docs -- had gone to the ER for common and highly appropriate conditions (think common respiratory and GI issues). Clearly, their claims management software automatically kicks out a few claims based on some factors known only to them -- most likely the ICD-9 code -- and they hope that the insured just eats the fee. They certainly made the appeals process complicated, until I called our reps to complain, at which point the penalties were magically dropped.

This is emblematic of the problems with the insurance industry. This was no mistake (as some commenters charitably ascribe insurance malfeasance to "errors"), these were automated rejections which are quite routine in the insurance industry -- you deny a certain fraction of claims on whatever impenetrable pretext you like, some of those you have to backtrack on and allow, but some never get appealed by beaten-down consumers and hey-presto - Profits! It's simple rational behavior of a business which is in the business of making money. Nothing mysterious about it.

Needless to say, we will be addressing this at our next renewal, either through a modification in the contract or re-opening the bidding process (sigh). The Assurant guys know this, and to the degree that they don't want to lose our business as a customer, I suspect that they will be willing to work with us. But it shouldn't have to be this way, that the insurers can pull every trick they can think of to deny care (or payment for care already rendered) and only have to back down when the employer goes to bat. Some of this will change under the HCR bill, but not too terribly much, sorry to say.

I had a minor surgical procedure today (I'm just fine, thank you). As usual, when I am incognito, I can't help tweaking the medical professionals just a bit. And since this was the outpatient surgical center, nobody knew I was a doctor. So I had a pleasant time chatting with the nurses and receptionists, they brought me back and got me prepped and hooked up. We chatted a bit about theamazing pharmacopoeiafound in Anna Nicole Smith's corpse. And then the anesthesiologist came in to do his pre-op bit, and going through his routine rapid-fire questions.

"We're going to be giving you an antibiotic in your IV. It's calledAncef. You're not allergic to anything, are you?""No." (He starts the IV running. After a moment, I remember) "Though once I had anaphylaxis toKefzol.""Did you take any medications this morning?""No. Well, only mycoumadin.""Why are you on coumadin?""I don't know. They never told me."

Rolling down the hall to the OR my stomach growled audibly. I groaned a little and rubbed my stomach. "Man, I shouldn't have had so much Gatorade this morning"

As they positioned me on the table and I started feeling a little light-headed from the Fentanyl I told him, "I was told once I might have myasthenia gravis. I hope that's not aproblem for you."

As I drifted off to sleep I told him I was going to be really pissed if I woke up with acolostomy. (I was not going in for an abdominal procedure.)

Fortunately, he had me figured out pretty quick. Which was good because I didn't actually want to get my case canceled. I really should be more careful, though, because payback can be a bitch. When I woke up I half-expected to see a faux colostomy bag taped to my belly.

To paraphrasePatrick O'Brien, nobody has ever taken so much pleasure from so very very little wit as I do.

18 March 2010

This is actually a pretty fair and reasonable smmary of the bill. I particularly liked the first point, which echoed my recent post:

1. The plan is not agovernment takeoverof health care like in Canada or Britain.The government will not take over hospitals or other privately run health care businesses. Doctors will not become government employees, like in Britain. And the U.S. government intends to help people buy insurance from private insurance companies, not pay all the bills like the single-payer system in Canada. The key parts of the current U.S. system -- employer-provided insurance, Medicare for the elderly, Medicaid for the poor -- would stay in place. The government would create health insurance exchanges for people who have to buy insurance on their own, so they could more easily compare plans and prices.

I might quibble with the phrasing of a couple of the points on technicalities, but overall, it's fair and unbiased, which is itself a rarity these days, and it gets the policy details more or less right, which is an even rarer and perhaps more valuable thing. Worth a read.

This also should be a headline, especially in the medical community, but for some reason is not.

Reform bill to increase Medicaid payments for primary care

The provision, would, over several years, bring Medicaid payments for primary care services up to the Medicare rate (which is itself too low but generally far outstrips the paltry remuneration offered by Medicaid). I was a bit unsure whether this provision had made it into the final bill, but the CBO score (Title I, Subtitle B, Sec 1202 for those keeping track at home) seems to imply that it did.

Why is this important? Well, first of all, the problems Medicaid patients experience regarding limited access to care have been well-reported and are linked to reimbursement levels for physicians. Which is not a surprise: when the overhead cost for an office visit (meaning rent, staff salaries, malpractice insurance) exceeds the reimbursement, the practice takes a net loss on each medicaid visit (and the physician is literally paying out of pocket for seeing the patient). So practices in state after state are either closing to new medicaid patients or refusing them entirely. If the compensation for at least some services rises to Medicare levels, more practices will open their doors to these patients.

In a way it is a pity that this is limited to primary care only, but I view this also as a first step. The need is certainly greatest in primary care, and I suspect and hope that this will in time be expanded to other specialties. The other thing that is good about this is that the cost differential will be borne by the feds (at least I think so -- anyone got a hard source on this point?) which is the first step towards federalization of the whole Medicaid program. It was a stupid and damaging accident of history that Medicaid wound up being state-administered while Medicare was national (if I recall correctly, it arose from the politics of race in the sixties, but I could be wrong). One of many problems about Medicaid is that the costs fall on the states' inelastic budgets hardest when states are experiencing the hardest economic conditions. States cannot run deficits, generally, and must balance their budgets every year. A recession produces huge shortfalls in revenue for the states, creating pressure to cut spending, while, at the exact same time, there are more unemployed and otherwise impoverished people signing up for Medicaid and increasing the costs. It's a Catch-22. If the program were federalized, excess costs from bad years could be rolled over into better economic times when enrollment wanes and revenues rise.

Additionally, fully federalizing Medicaid would allow for standard eligibility criteria (which currently vary wildly from state to state). The HCR bill does start this process with its expansion of eligibility to all people under a certain income level (100% FPL, I think). Currently Medicaid is in many states limited to the "deserving poor," meaning those with dependent children and those below some arbitrary level of income (in some states it's ridiculously restrictive). Again, the expansion is funded by the feds, I think at least in part or for a limited time.

Federalizing Medicaid would also allow streamlined enrollment. Many of the uninsured are without coverage even though they would be eligible for Medicaid. This is in part due to apathy or ignorance, I am sure, but also in part due to the fact that many states set onerous rules for applicants. Difficult requirements for documents, in-person interviews, and lengthy and oft-delayed review processes weed out many applicant who are dim, less-than-highly committed, or just disorganized. Whether this is by design, to limit enrollment and hence costs, or by accident, either way it prevents many folks who ought to have this coverage from getting it. A federal program would greatly increase access to eligible Americans.

What a great talking point. I'm not being snarky -- it really is well-crafted. It's succinct, pithy, and memorable. It clearly encapsulates why conservatives oppose the reform effort. It's a great tool to get the message out over teevee media outlets. It's also completely misleading.

Take a moment to review the numbers:

US GDP - $14 Trillion (2008)Total spending on health care in the US - about $2.25 Trillion, or about 16% of GDP Total cost of the health care bill annualized over the first decade - $94 Billion

You know, these trillions-billions comparisons of dollars get confusing, so for perspective, I'm going to switch to billions exclusively. And a few other numbers for comparison:

Yeah, yeah, I know -- a billion here, a billion there and pretty soon you're talking real money. The point, however, should be pretty clear: $94 Billion a year is a lot, but it is a drop in the bucket compared to the overall cost of US health care. It's hardly a "takeover" and laughably not "one-sixth of the economy" that will be affected.

Now some people will immediately object that the cost may be small but the effects will be propagated through the rest of the health-care sector, that the impact of this bill is much father reaching than the simple cost alone. And you know what? They're right. That's one of the two key reasons to enact reform: the inflation of health care costs has averaged 8% per year -- far, far above the general inflation rate or the growth of GDP. It's unsustainable. So the fact that the HCR bill will impact the rest of the industry is a feature, not a bug. In fact, most people agree that in this facet, the HCR bill is if anything too small and too limited in its scope. I think it's a good start -- but just that, a start. Whether cost-effectiveness research or the Independent Medicare Advisory Commission wind up paying off in cost savings will take quite a while to assess.

And it's not a takeover. 265 million Americans will not see the source of their personal health insurance change. The vast majority of working Americans will remain in their employer-sponsored plans. The 83 million Americans on Medicare and other government-funded insurance will retain it. The only change will be for the 30 million uninsured whom the CBO estimates will find coverage through the insurance exchanges or will be moved into government-sponsored plans. And of course for those who are currently in the individual market whose premiums will go down. I'll continue to work in a fee-for-service system with 80% of my revenue coming from private insurers, as will most doctors and hospitals.

Are there going to be changes? Yes, there need to be. Are there going to be challenges and secondary consequences which need to be dealt with? You bet. There are not, however, any structural changes that justify the hyperbolic phrase "government takeover." We are not killing the private delivery system of health care, we are not killing the private funding of most health care. We are not going to single payer land (Canada) or socialized medicine (England).

Overall, this HCR bill is small and limited in its approach and goals -- a small-c conservative approach to HCR. And the folks who parrot the "takeover" meme are either being disingenuous or are ill-informed. I wish they would knock it off.

It's kind of depressing to see how few actual facts make it into the mainstream media's narrative and thus into the conventional wisdom. I don't mean to pick on anybody in particular, but let's use this post from The Central Line as an example of the confusion that has been generated by the media coverage of this dynamic process. Much of the confusion, I might add, has been willfully perpetrated by the agenda-driven folks at Fox News and various other conservative pundits. Their brethren, however, in the fact-based media, have completely failed in making the basic facts about the health care reform bill available and understood by the electorate.

Dr Mattke poses the following questions:

I also missed the math class in school that allowed you to save money and still spend it- I’d like to be able to do that in my own expenses. [...] Are we really talking about adding a trillion dollars to the deficit that we can’t pay now? Doesn’t the word “deficit” mean that we can’t pay it now?

[...] I’m confused and want to know- is tort reform in or out? Is the public option in or out? Is the opening of health insurance sales across state lines in or out? Are we still voting on the bill? Because it doesn’t sound like congress is even going to vote on the bill, but on the second derivative of the bill, and this violates the principles of SchoolHouse Rock in which the rules were clearly laid out.

Sigh.

The deficit. We're all concerned about that now, aren't we? Pity the Republicans who passed Medicare Part D in 2003 were not so concerned about the largest deficit in history back then and made no attempts whatsoever to fund the largest expansion of health care in US history -- they just spent the money and tacked on well over a trillion dollars to the deficit without a care. But that's water under the bridge to the GOP now that they are in the minority and it's a Democrat trying to spend some money -- they've rediscovered their aversion to deficits.

Which is why it's noteworthy -- headline-worthy for that matter -- to point out this simple fact: The Health Care Reform bill is fully paid for. More than fully paid for.

The Health Care Reform Bill reduces the deficit.

Got that? Reduces the deficit. Makes it smaller. Saves money.

But how is that possible? By what black magic is it possible to spend money and save money at the same time? By what perversion of the arithmetic we all learned in grade school can increased spending result in more money in the bank?

It's actually not that hard. You see, health care reform does involve spending more money -- principally on the subsidies for low- and middle-income individuals' purchase of insurance. But that's not all that is in the bill. There are new funding sources that bring in more money, and there are offsets that reduce spending in other areas. Specifically, there are new taxes on high-cost insurance plans and on investment income for wealthy taxpayers, among others. The Medicare Advantage program pays more to insurers who provide private Medicare insurance than the actual cost of the insurance; these overpayments will be phased out. There are expected cost savings from the cost control elements of the bill (yes, they do exist) although these are not scored as saving as much as some people expect. This actually means that if the cost controls work better than the CBO estimates (the CBO used the lowest savings model from these measures) the bill may be even more effective at reducing the deficit. This is now new news, by the way. The House bill (now dead) which passed in November, also reduced the deficit; the Senate bill passed Christmas Eve reduced the deficit by $118 billion.

How big is the deficit reduction under the amended Senate bill? $138 Billion over the next ten years. That's a lot. There are some claims that these savings are not "real" in that some of the taxes begin to be collected before the costs are incurred, and to a degree there is some pre-payment of the costs. The criticism is, however, fallacious, since the estimates of cost savings actually increase in the bill's second decade. Obviously, such long-range projections have larger error bars, but the CBO estimates that the second decade of the bill would reduce the deficit by one-half of a percent of GDP. when you are talking fractions of GDP, by the way, the numbers are really big.

If there's one thing that you should take away from the bill -- whether you think it's too big or too small or too friendly to insurers or just pure soshalism -- it is this simple fact: it is fully paid for. The CBO is a tough customer in its demands and they require even the worst-case numbers to reduce the deficit before they will endorse it as deficit-reducing.

As for Dr Mattke's other questions: no tort reform, no public option, inter-state insurance exchanges by compact between states, and yes there will be a vote, a combined vote on the bill and the fix, referred to as "Deem and Pass." (Despite the hypocritical GOP outcry over the process, this sort of procedure, like reconciliation, is perfectly accepted and was used extensively by the Republicans when they controlled Congress.)

17 March 2010

Hope you get a chance to raise a Guinness this fine evening. I'll be home with the family, but will celebrate in spirit with all of you.

As for the promised Baldrick's update -- I'm sorry I didn't get a chance to post it earlier, but here goes:

The family and I arrived at the Fadó Pub in Seattle at about 6 on Monday and met up with fellow physician-blogger and shavee Carlos V and his family. Carlos, a pediatrician, and his wife, a pediatric oncologist, had recruited a couple of their cancer kids to help with the shaving! Both kids, curiously, were named Angel. They each took the first few swipes with the razors (with a good-natured attempt to get the eyebrows as well!) and there was much rejoicing.

Unfortunately, the pub was loud and crowded and it was a school night, so we couldn't stay as long as we might have liked, and after only three pints of Guinness we had to take off. (Funny note: I've gotten addicted to the big hop taste of Pac NW beer, to the point that I no longer enjoy Guinness as I once did. But, in an Irish pub, on tap, drunk from a pint glass, it's as wonderful as it ever was.)

The razor job from the pub is always a little rough, and I generally don't feel that I've given my donors their money's worth unless I go clean, so when I get home I got a good sharp razor blade and cleaned it down to the skin (YOU try doing that after a few pints of Guinness!) nice and smooth. It always shocks me how temperature sensitive my scalp is after going bald! I feel every gust and draft of air, and if I should walk under an unshielded light bulb in reflexively flinch away from the heat! Crazy. Also, the stubble after a few hours is like velcro when you pull a t-shirt over your head and you reliably wrench your neck until you learn to compensate for the extra friction.

I figure that I'll keep it clean shaven for a couple of weeks before letting it grow back out. I'm really just delaying the inevitable -- I look OK bald, but the fuzzy growing-out period is quite comical looking.

12 March 2010

My neighbor's kid constructed this ramp:I am not sure what use he intends to put it to. He skates and rides a dirt bike on the streets around here, though not with any great skill, it must be said. But I kind of admire his chutzpah -- by my eye, that thing takes off at about a 45-degree angle. Unfortunately, I've got to go to work soon, so I won't be around to witness the excitement.

10 March 2010

I was reading a white paper on health care cost savings written by the Center on Budget and Policy Priorities (cause that's just the way I roll) and the following passage jumped out at me:

In arguing that Medicare cuts never “stick,” critics point in particular to Congress’ repeated refusal to let the reductions in physician reimbursement rates under Medicare’s so-called “sustainable growth rate” (SGR) mechanism, which it enacted in 1997, take full effect. The SGR cuts, however, represented a badly designed measure that was not intended to produce large savings (the projected SGR savings represented less than five percent of total Medicare savings in the 1997 bill), but turned into a blunt instrument that would have produced cuts far in excess of what was anticipated and would have had harsh and indefensible effects. (Moreover, even though Congress did not allow the full cuts required under the SGR formula to take effect, it has still cut the physician reimbursement rate substantially — at its current level, the reimbursement rate in 2010 will be 17 percent below the rate for 2001, adjusted for inflation.) The SGR mechanism has little in common with most of the other provisions that Congress has enacted over the years to produce savings in Medicare and that have, in fact, taken effect. This distinction is important because most of the Medicare savings provisions in the House and Senate health reform bills are similar in nature to the types of Medicare provisions that Congress has enacted in the past that have taken effect — and they differ markedly from the blunt-instrument design of the SGR cut.

File that under "So what's news about that? Everybody knows that medicare rates have been flat for the last decade." True, true. I had just never bothered to go back and do the math and see how it all adjusted out for inflation.

While the declining Medicare reimbursement has been bad for Emergency Medicine, it's been catastrophic for primary care and other office-based cognitive practices. For our business, overhead is fairly stable and small compared to overall revenue streams. Typical ER practices pay 15-25% of revenue to fixed cost items like malpractice insurance, billing, and back-office operations, and the rest goes to provider payroll -- the only floating variable for private physician practices. So declining reimbursement has its effect entirely on payroll. But primary care practices face a totally different dynamic. They have many fixed expenses in addition to those we bear: they pay rent, nurses and techs and secretaries, healthcare costs for their employees, equipment, scheduling software, etc etc. The fixed costs portion of a typical office practice can be much higher, consuming 60-80% of gross revenue. Worse, many of these "fixed costs" for primary care are not truly fixed, but increase annually consistent with inflation (or exceeding inflation, in the case of health insurance benefits for employees).

The result of the higher practice costs is that if you assume that an EM and Internal Medicine practice both see a volume of 20% medicare patients, and the cuts in medicare result in a 3% revenue decrease, the EM docs will see a 4% decrease in salary while the IM docs will see a 10% cut. (Note that over the same period compensation would have needed to increase by 25% just to remain at baseline, due to inflation.) Add to that the fact that practice expenses are steadily increasing, further eating into primary care compensation, and it's a wonder that there are any primary care doctors still in private practice at all. It's become a non-viable business model.

I predict that if nothing else changes in the overall model of physician reimbursement (and HCR does not seem to promise very much, even if it passes) that within a decade there will be almost no independent primary care left in existence -- they will all have been subsumed into hospital-owned or group practices to serve as "loss leaders," existing solely to drive referrals to profit centers like surgical services and imaging facilities.

This is, by the way, Argument Number One against single payer. Centralized payment schedules will inevitably decline, whether by accident (as in the case of the SGR) or due to budgetary pressures, or both.

Across the political spectrum, myopia is the order of the day. A few recent items give expression to this myopia.

Begin with the left. Without a doubt, Obama's proposals would leave the health care system far short of what most progressives, myself included, would design in the absence of political constraints. But also without a doubt, it would lift the system far above the status quo that is the only near-term alternative. Here it is, the most dramatic improvement in social justice in at least four decades fighting for its life in the home stretch, and the left can barely be roused to fight for it. The somnolence is far from universal, but on the left there is at least as much passion against health care reform as for it. One of many considerations the vulnerable Democratic moderates who hold reform's fate in their hands must balance is, in return for the limitless rage of the right, will they get any credit from the left for backing this reform? At the moment when every voice counts, when every ounce of pressure could prove decisive, here isFireDogLake:

Lynn Woolsey says she’s a definite “yes” vote on the Senate health care bill. Even if it lacks a public option. Despite the fact that it’s the biggest blow to a woman’s right to choose in a generation, and may come at the price of a stand-alone vote that allows Blue Dogs and ConservaDems to join with Republicans and roll them back even further in order to get Bart Stupak’s support. ... It’s time for Lynn Woolsey to resign as the head of the Progressive Caucus.

Yes,thatis what it is time for! One day, when progressives study this moment in history, they will evaluate all of us by this single standard: What did they do to stop Lynn Woolsey?

The right, meanwhile, has whipped itself into a spiraling rage of ideological fanaticism and grotesque partisanship. Republicans have convinced their base that a close replica of the 1993 Senate Republican health care plan and Mitt Romney's Massachusetts reform is socialism and the end of freedom in America, and as the base spins further out of control, it drags the party still further into scorched-Earth opposition. Thus the Republicans who saw the need for reform were whipsawed one by one by the base and the party leadership into abandoning all negotiations.

The latest Republicangambit, put forward by John McCain (who has become a pure stalking horse for the party leadership) is to demand that no change to Medicare be permitted through budget reconciliation. This means that the very difficult task of getting a majority of both Houses to approve a Medicare cut would become the nearly-impossible task of getting a majority of the House plus asupermajorityof the Senate to do the same. Of course, Republicans as well as Democrats have used reconciliation numerous times to wring savings out of Medicare. But this proposal is not just the usual staggering hypocrisy. The immediate purpose is to render Obama's health care reform impossible. But the long term effect would be to render anyRepublicanreform impossible. How do Republicans propose to fulfill their vision of government when any forty Senators can block a dime of Medicare cuts? Don't theyeveraspire to govern?

Sigh. That pretty much sums it up. Clowns to the left of me, jokers to my right. Here I am.

Alternate Health Care BillsIn response to President Obama's call for compromise, several lawmakers have concocted their own health care reform bills. Here are some provisions of the top contenders:

Hoyer-Larson Bill: All 45 million uninsured Americans would be guaranteed medical care, all of it provided by Dr. Tom Janicak of Houston, TX

Melancon-Cooper Bill: Would create a low-cost government-administered health insurance plan, but would prohibit anyone from buying into it

Griffith-Cantor Bill: Low-income families would be allowed to huddle outside hospital windows in the cold and look at wealthier families receiving care

Hutchinson-Snowe Bill: Children insured on a cuteness scale

Murray-Menendez Bill: Doctors only allowed to mention giving birth as a viable alternative after providing counseling on the many different ways one can have an abortion.

Luetkemeyer-Fortenberry Bill: They just liked the way their names looked together, and this seemed like the most high-profile opportunity to put it out there

Grayson Bill: Rep. Alan Grayson will personally punch in the face any insurance executive who turns down a valid claim

Blookross-Feiser Bill: Although no one is exactly sure who these two shadowy congressmen are, their bill would mandate a twofold increase in insurance premiums and force patients to buy name-brand drugs

I particularly like the Melancon-Cooper bill, which actually does bear resemblance to the Public Option in its death throes.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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